Many of the weaknesses and failures that were found have been addressed by stakeholders, by the time of the inquest. Nevertheless, the evidence revealed matters that still give rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. 1. The system of placements at transition

The YOT worker said that it was a problem having a sudden change of duties aged 18 and it would better if legal duties were kept in parallel with their work until the Transition Plan was completed. The Head of Placements and Safeguarding at YJB was taken to an extract of the YOT worker's reflections on the operation of the transition system, in which she said that historically there was an approach that when you are 18, our role just stops, (that did not occur here). The famous civil servant, said that "officials are the servants of the public and the official must not try to foster the illusion it is the other way round". She was asked whether Imran Douglas had to fit into the system rather than the system serve him. She agreed that a more flexible policy was needed. She agreed that the Transition Process was bureaucratic, and to work, it depended on good will. She agreed that there was an inherent risk from the statutory change of duties at 18, especially when staff were under pressure, but was concerned if legislative change adds to bureaucracy. The Deputy Director of NOMS agreed that it made no sense that there was an legal hand over of roles at 18 years: it would be better if handover of responsibility took place when the Transition Plan was completed. I consider that there is an outstanding risk that, when a rising 18 enters the criminal justice system with insufficient time for the normal Transition Plan, and especially when staff are under pressure, that even with the changes in placements from courts that have been made, and the Joint National Protocol, the knowledge and expertise of the YOT and YJB may not be properly considered in a placement if the legal duty for placement has passed to the PMU before the Plan is complete. The Secretary of State is asked to consider whether a person based rather than rule based system would be safer, by legislating to allow flexibility for YJB and YOTs to decide when the duty for placement is passed to the PMU, in line with the completion of the person's Transition Plan, rather than rigidly on the 18th birthday.
2. The adequacy of knowledge and interagency working between social care in London Borough of Tower Hamlets and the secure estate. Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning. A social worker said that the LAC plan was "potentially informative" but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was. The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff. This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
3. The adequacy of electronic communication systems between agencies The jury criticised the lack of access of HMP Belmarsh to the E Asset system and the fact that key documents from the Secure Training Centre were never accessed by the secure estate. The lack of a universal system of records throughout the offender's pathway results in information on risk not being known to others and may contribute to future deaths.
4. The competence of a medical practitioner, who no longer is employed in health care in HMP Belmarsh, but is on the GMC register and may practice elsewhere and as a general practitioner. The GP did not record history or examination or propose any interventions despite being aware of the young age, long sentence and suicide warning from court. The clinical review conducted as part of the Prison and Probation Ombudsman's Report concluded that health care provision in HMP Belmarsh was below the standard expected. The GMC Fitness to Practice Directorate is asked to consider whether an assessment of his clinical practice is indicated. 7